- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.04 / $739.87 / $872.03
| Professional | | $536.04 | $739.87 | $872.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.27 / $706.26 / $1,107.50
| Professional | | $510.27 | $706.26 | $1,107.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.22 / $913.10 / $1,193.90
| Professional | | $733.22 | $913.10 | $1,193.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.86 / $827.57 / $1,256.33
| Professional | | $504.86 | $827.57 | $1,256.33 |